ORIGINAL

Niger J Paed 2013; 40 (1): 24 –29

Mothers and childhood pneumonia:

what should the focus of public

campaigns be?

Ekure E.N

Esezobor CI

Balogun MR

Mukhtar-Yola M

Ojo OO

Emodi IJ

Omoigberale AI

Oviawe O

Ezechukwu CC

Olowu AO

Ogala WN

Esangbedo DO

DOI:http://dx.doi.org/10.4314/njp.v40i1.4

Accepted: 30th July 2012

Olowu AO

Department of Paediatrics, Ogun State

Teaching Hospital, Sagamu. Nigeria.

Prior to the study, 16 (15%) had not

heard about pneumonia. About half

of the participants correctly identi-

fied fast/difficult breathing as sug-

gestive of pneumonia. Three-

quarters reported exposure to cold

as the cause of childhood pneumo-

nia. Minimizing exposure to cold

and wearing warm clothes were the

two commonest reported ways of

preventing pneumonia (75.8% and

Ekure E.N

(

)

Esezobor CI

Department of Paediatrics,

Esangbedo D.O

Paediatric Unit, Providence Hospital,

Lagos, Nigeria

Balogun M R

Department of Community Health and

Primary Care

College of Medicine, University of

Lagos, Lagos University Teaching Hos-

pital, Lagos, Nigeria.

Abstract Background: Prompt ad-

ministration of antibiotics to chil-

dren with pneumonia significantly

reduces the probability of death.

However this requires early identifi-

cation of such children in the com-

munity. In a country such as Nigeria

with one of the highest pneumonia-

related deaths, what do mothers

know about pneumonia, and what

should be the content of public cam-

paign messages?

Methods: A structured questionnaire

was administered to mothers attend-

ing paediatric clinics of Lagos Uni-

versity Teaching Hospital seeking

their knowledge about the defini-

tion, causes, risk factors and symp-

toms of childhood pneumonia.

Email: ekaekure@yahoo.com

4

9.5% of the mothers respectively);

in contrast hand washing, exclusive

breastfeeding and limiting exposure

to sick persons with cough and ca-

tarrh were the least mentioned. The

proportion of mothers who cor-

rectly identified fast/difficult

breathing as suggestive of pneumo-

nia was similar irrespective of edu-

cational status or source of pneumo-

nia information.

Conclusion: Mothers’ knowledge of

childhood pneumonia is low. Public

campaigns on pneumonia should

focus on raising awareness about

germs as cause of pneumonia, im-

munization, hand washing and ex-

clusive breastfeeding as potent pre-

ventive strategies and fast/difficult

breathing as a feature of pneumo-

nia.

Mukhtar-Yola M

Department of Paediatrics, National

Hospital, Abuja

Ojo OO

Lagoon Hospital, Lagos

Emodi IJ

Department of Paediatrics, University

of Nigeria Teaching Hospital, Enugu,

Nigeria

Omoigberale AI, Oviawe O

Department of Paediatrics, University

of Benin Teaching Hospital, Benin

City, Nigeria

Results: One hundred and seven

Ezechukwu CC

(

107) consecutive mothers partici-

Department of Paediatrics, Nnamdi

Azikiwe University Teaching Hospital,

Nnewi, Nigeria

pated in the study. The majority (97;

90.6%) had at least secondary edu-

cation, were married (96; 89.7%)

and professed to be either Christians

or Muslims (105; 98.1%).

Ogala WN

Department of Paediatrics, Ahmadu

Bello University Teaching Hospital,

Zaria, Nigeria

2

5

Introduction

tions on ways of preventing pneumonia. Each respon-

dent was asked what they would do if their child had

pneumonia. To improve completion rate each question

(except the question on age of caregiver) had multiple

choices and caregivers were encouraged to choose as

many correct options as possible for each question. For

the caregivers who could not read in English the ques-

tionnaire was administered to them by one of the inves-

tigators.

Pneumonia is one of the leading causes of childhood

mortality worldwide, with the burden highest in devel-

oping countries such as Nigeria. Fortunately, immuni-

1

zations against Streptococcus pneumoniae and Haemo-

philus influenza, the two commonest causes of severe

pneumonia, have made h₃uge reduction in pneumonia

2

morbidity and mortality. However, these vaccines are

not universally available with significant non-coverage

in regions of the₃₄world where pneumonia-related deaths

are the greatest.

The socio-demographic features of the subjects were

presented as proportions or as mean (SD). With multiple

options per question the number of respondents who

chose an option was summarized as a proportion of the

total number of possible responses. Characteristics of

groups were compared using Chi Square (or Fisher’s

exact test) or student t test as appropriate. A p value less

than 0.05 was considered statistically significant.

Even after a child has developed pneumonia prompt

institution of appropriate therapies including antibiotics

5

significantly reduce the probability of death. However

such a child with pneumonia needs to be identified at

6

home as sick and needing prompt medical attention.

Therefore if the caregiver fails to realise the immediacy

of medical treatment for a child with pneumonia the

child may not be brought to the attention of health prac-

7

titioner and is consequently at risk of a worse outcome.

The early recognition of the features of pneumonia by

the caregiver at home is more so important in malaria-

endemic regions like Nigeria where family-initiated

treatment of febrile illnesses as malaria is encouraged,

with potential delays in brin₇g₈ing the child to the atten-

tion of health care providers.

Results

Demographics of the study participants

A hundred and seven (107) consecutive caregivers, all

mothers, participated in the study. The majority (97;

90.6%) of the participants had secondary or post secon-

dary school education, were married (96; 89.7%) and

belonged to the two major religions of Christianity and

Islam (105; 98.1%). Over half (57.9%) were of the

Yoruba ethnic group while 31 (29%) belonged to the Ibo

ethnic group (Table 1).

Previous studies from developing regions of the world

where the burden of pneumonia is high have docu-

mented that mothers’ know_-₁₁ledge of the common fea-

9

tures of pneumonia is low. As part of a programme of

events during the year 2011 World Pneumonia Day, the

Paediatric Association of Nigeria (PAN) undertook the

present study to document mothers’ knowledge about

the common features, major risk factors and causes of

childhood pneumonia. The findings of the study would

guide the development of campaign resources for public

enlightenment about community acquired childhood

pneumonia.

Table 1: Socio-demographics of Participants

Characteristics of Respondents

n (%)

Marital Status

Married

Single

96 (89.7)

8 (7.5)

Separated/Widowed

Religion

Christianity

Islam

3 (2.8)

73 (64.2)

32 (29.9)

2 (1.9)

Others

Tribe

Yoruba

Subjects and Methods

62 (57.9)

31 (29.0)

1 (0.9)

Ibo

Hausa

Others

Level of Education

None/Primary

Secondary

Post secondary

Heard of pneumonia before

Yes

No

Sources of information on pneumonia

News Media

Friends/Relatives

Health workers/Facility

Others (e.g. victims, books)

Throughout the second week in November 2011, moth-

ers of children attending the Immunoprophylaxis and

Well baby Clinics of the Lagos University Teaching

Hospital (LUTH) were invited to participate in the

study. Lagos University Teaching Hospital is a fee-

paying, public-funded tertiary hospital located in Lagos.

It provides all levels of care, including primary care, to

the residents of Lagos state and neighbouring states.

After obtaining informed consent each caregiver was

administered a structured questionnaire eliciting their

knowledge and care seeking behaviour about commu-

nity acquired childhood pneumonia. The section on

knowledge of pneumonia had questions on definition of

pneumonia, risk factors and causes of pneumonia and

symptoms suggestive of pneumonia. Others were ques-

13 (12.1)

10 (9.3)

38 (35.5)

59 (55.1)

91 (85.0)

16 (15.0)

*

21 (23.3)

41 (45.6)

27 (30.0)

7 (7.8)

*Total number more than 107 because of multiple responses

2

6

Sources of information on pneumonia

Features of pneumonia

Only 91 (85%) participants reported previously hearing

about pneumonia; one of which did not complete the

other sections of the questionnaire leaving 90 for analy-

sis. Among those who reported knowledge of pneumo-

nia ‘Friends/Relatives’ (41; 45.1%) was the commonest

source of information about pneumonia. ‘Health work-

ers/Facility’ and ‘News Media’ were reported as the

second and third most frequently reported sources of

information on pneumonia respectively (Table 1).

Over half (53.8%) and 42 (46.2%) participants correctly

identified ‘fast or difficult breathing’ and ‘fever’ respec-

tively as features of a child with pneumonia (Fig 3).

Prevention of pneumonia

Minimizing exposure to cold (69; 75.8%) and wearing

of warm clothes (45; 49.5%) were the most frequently

reported ways of preventing childhood pneumonia. Lim-

iting exposure to persons with cough and catarrh, hand

washing and breastfeeding were the least commonly

reported ways of preventing pneumonia. Immunization

as a preventive strategy was chosen by 24 (26.4%) par-

ticipants (Fig 3).

Knowledge of what pneumonia is

Forty eight (53.3%) participants described pneumonia as

infection of the lungs, 17 (19.5%) as cough and catarrh,

1

as a cold. (fig 1)

7 (19.5%) didn’t know while the remainder described it

Except for one, all the participants responded that the

correct action to take when a child develops pneumonia

is to take the child to the hospital/medical doctors.

Fig 1: Respondents’ knowledge of the definition of

pneumonia

Fig 3: Respondents’ knowledge of symptoms and ways

of preventing pneumonia

Risk factors and causes of pneumonia

The majority (68; 74.7%) of the participants identified

exposure to cold as the cause of pneumonia. In contrast

only 21 (23.1%) participants chose ‘germs’ as causes of

pneumonia. Concerning the risk factors for childhood

pneumonia the two most commonly identified risk fac-

tors were ‘being under the age of five years’ and ‘an

underlying lung disease’. The two least commonly iden-

tified risk factors for pneumonia were ‘lack of exclusive

breastfeeding’ and ‘attending a child day care

Factors associated with the correct knowledge of pneu-

monia

Having a post secondary education was associated with

correctly identifying pneumonia as an infection of the

lungs (64.3% v 38.2%) and exclusive breastfeeding as a

risk factor (23.3% v 5.9%) for pneumonia. Identifica-

tion of features of pneumonia, germs as cause of pneu-

monia and other risk factors for pneumonia were similar

between participants with post secondary education and

those with lower educational level (Table 2). Partici-

pants whose source of information on pneumonia was

from the news media were more likely to identify expo-

sure to cold as cause of pneumonia. They were also less

likely to identify germs as causes of pneumonia though

this was not significant (9.5% v 29.0%; p=0.069) (Table

centre’ (Fig 2).

Fig 2: Respondents’ knowledge of the causes and risk

factors of childhood pneumonia

3

). Participants who reported health workers/facility as

sources of pneumonia information were more likely

identify germs as cause of pneumonia (40.7% v 17.5%)

and lack of exclusive breastfeeding as a risk factor for

childhood pneumonia (33.3% v 9.5%) (Table 4).

EBF: exclusive breastfeeding; LBW: low birth weight

2

7

Table 2: Correct Responses stratified by Educational Status

Discussion

Statements about

pneumonia

Tertiary Education, n=90

P value

Correct and early identification of a child with pneumo-

nia at home allows for prompt referral to health facilities

where administration of appropriate antibiotics increases

the probability of a better outcome. This strategy of re-

ducing pneumonia deaths takes a greater significance in

developing countries such as Nigeria where potent vac-

cines against Streptococcus pneumoniae a₃ n₄ d Haemophi-

lus influenza are not routinely available. These obser-

vations underlined the conduct of the present study

which documented that the correct knowledge about

causes, features, risk factors and strategies of preventing

community acquired childhood pneumonia is low

among mothers.

No

Yes

n=34 (%)

n=56 (%)

Pneumonia is infection of

the lungs

Germs are causes of pneu-

monia

Exposure to cold causes

Pneumonia

Day Care attendance is a

risk factor

13 (38.2)

7 (20.6)

27 (79.4)

2 (5.9)

36 (64.3)

15 (26.8)

42 (75.0)

7 (12.5)

0.016

0.507

0.631

0.263

Lack of EBF is a risk factor 2 (5.9)

13 (23.3)

34 (60.7)

0.032

0.859

Fast/Difficult breathing is a

feature of pneumonia

Reducing exposure to cold

prevents pneumonia

Hand washing prevents

pneumonia

20 (58.8)

22 (64.7)

6 (17.6)

41 (73.2)

6 (10.7)

0.393

0.265

With pneumonia among the three biggest killers of chil-

dren in Nigeria it came as a surprise that only about half

of the mothers who reported ever hearing of pneumonia

correctly identified pneumonia as an infection of the

lungs. Moreover, 15% of the participants had never

heard of pneumonia. Similar, and in some cases, poorer

results have been documented from other regions of the

world, espe₆c₉i₁a₀lly when study populations were from

Table 3: Correct Responses stratified by sources of in-

formation on Pneumonia (News Media versus others)

Statements about

pneumonia

Source of information on pneu- P value

monia, n=90

News Media

n=21 (%)

Other Sources

n=69 (%)

rural areas.

These findings argue for more intense

Pneumonia is infection of

the lungs

Germs are causes of pneu-

monia

Exposure to cold causes

pneumonia

Day care attendance is a

risk factor

12 (57.1)

37 (53.6)

20 (29.0)

11 (15.9)

7 (10.1)

0.777

0.069

0.004

0.650

0.517

0.416

0.870

0.172

public enlightenment campaigns about pneumonia such

as those for measles and malaria that have largely suc-

ceeded in creating huge awareness.

2 (9.5)

10 (47.6)

2 (9.5)

Fast and or difficult breathing as a cardinal feature of

pneumonia was only reported by about half of the re-

spondents in the present study; with the likelihood that

in the other half children with fast/difficult breathing

may not be identified as having pneumonia and referred

to a healthcare provider. This finding is similar to the

repo₂rt of another study from an urban centre in Nige-

Lack of EBF is a risk

factor

3 (14.3)

11 (52.4)

6 (28.6)

1 (4.8)

12 (17.4)

43 (62.3)

21 (30.4)

11 (15.9)

Fast/Difficult breathing is

a feature of pneumonia

Reducing exposure to cold

prevents pneumonia

Hand washing prevents

pneumonia

1

ria. In general most studies from developing countries

such as Ethiopia, Pakistan and Honduras are unanimous

that mothers do not recognize the₉₁f₀e₁a₃tures of pneumonia

such as fast/difficult breathing.

Because cases of

childhood community-acquired pneumonia are com-

monly preceded by nasopharyngeal infection (common

cold) which only requires supportive care at home, fail-

ure to recognize fast/difficult breathing as a complica-

tion of common cold requiring prompt medical attention

has been associated with increased morbidity and mor-

Table 4: Correct Responses stratified by sources of Informa-

tion on Pneumonia (Health workers/ Facility versus others)

Questions

Source of Information on

Pneumonia, n=90

P

value

Health

Other

Workers

n=27 (%)

Sources

n=63 (%)

7

tality from pneumonia. The ability of caregivers to rec-

ognize fast/difficult breathing as a trigger for self refer-

ral assumes additional implication in malaria-endemic

countr₇ie₈s where home management of malaria is advo-

cated. Because fever is a common feature of both

pneumonia and malaria it becomes more important for

caregivers to recognize that the presence of fast/difficult

breathing in a child with fever should prompt referral to

a health facility in order to prevent significant morbidity

Pneumonia is infection of the 15 (55.6)

lungs

34 (54.0) 0.890

11 (17.5) 0.019

14 (22.2) 0.703

Germs are causes of pneu-

monia

11 (40.7)

7 (25.9)

5 (18.5)

9 (33.3)

15 (55.6)

12 (44.4)

6 (22.2)

Exposure to cold causes

pneumonia

Day care attendance is a risk

factor

4 (6.3)

6 (9.5)

0.087

0.008

Lack of EBF is a risk factor

8

and mortality. Results from pneumonia campaigns from

Fast/Difficult breathing is a

feature of pneumonia

Reducing exposure to cold

prevents pneumonia

Hand washing prevents

pneumonia

39 (61.9) 0.573

15 (23.8) 0.050

different regions of the world have demonstrated signifi-

cant improvement in pneumonia deaths when messages

emphasize the need for prompt referral to the health

facil₅i₁t₁y when children develop fast or difficult breath-

6 (9.5)

0.102

ing.

With almost all the respondents in the present

study correctly reporting that they will take their child

2

8

with suspected pneumonia to the hospital/doctor, cam-

paigns aimed at teaching them how to recognize this

feature of pneumonia are likely to result in fewer deaths

from pneumonia.

enlightenment there is a need to target the media practi-

tioners as part of campaigns to improve knowledge of

childhood pneumonia and reduce pneumonia –related

deaths. Our findings also suggest that the pneumonia

campaigns should not be targeted at mothers only, but at

the general population because ‘friends/relatives’ was

the commonest source of information on pneumonia.

Fewer mothers in the present study knew the causes of

pneumonia and its common risk factors. Similar to most

pneumonia surveys world wide exposure to cold and

change in weather were₁t₁h₁e₃₁c₄ommonly cited causes for

Our study has some limitations. We studied mothers

attending the hospital rather than in the community,

hence our sample may not be representative of the gen-

eral population and may have explained the higher pro-

portion with the correct knowledge and care-seeking

behaviour about childhood pneumonia in the present

study. Some of the respondents had the questionnaire

read to them because they could not read, and this could

have introduced some bias; however, the majority of

these respondents had not heard of pneumonia before

the study and therefore had minimal effect on the study

because they were excluded from subsequent analysis.

pneumonia by mothers.

This reflects the widely

held public view that pneumonia results from exposure

to cold air. This view has been reported among Peru-

vian, Pakistani and Nigerian mothers and explains why

mothers employ war₁m₀₁t₁h₁₅producing measures as treat-

ment for pneumonia.

In the present study reducing

exposure to cold, wearing of warm clothes and use of

heat producing balms such as menthol were the com-

monly cited strategies to preventing pneumonia. Recog-

nition of germs as the cause of pneumo₁n₁ i₁a₅ was poor in

the present study, as in other surveys.

In the same

vein, factors that predispose a child to getting an infec-

tion such as lack of exclusive breastfeeding, malnutri-

tion, overcrowding and day care attendance were infre-

quently mentioned by the vast majority of the respon-

dents in the present study. Not surprisingly the impor-

tance of immunization and hand washing as potent

strategies in preventing pneumonia was not appreciated.

These measures, including exclusive breastfeeding, need

to be emphasized in campaign messages because they

have been demonstrated to have huge im₂p₃ac₁₆t₁o₇ n pneu-

monia-related morbidities and mortalities.

Conclusion

Knowledge of fast/difficult breathing as a cardinal fea-

ture of pneumonia is modest among Nigerian mothers.

Knowledge of cause, risk factors and family-level pre-

ventive strategies of pneumonia is even lower. Pneumo-

nia campaign messages should target the general popula-

tion, and not mothers only, emphasize the recognition of

fast/difficult breathing and the need for prompt referral

of children with fast/difficult breathing to an appropriate

healthcare provider

Respondents with less than tertiary education were less

likely to have the correct knowledge about some aspects

of pneumonia. Two areas where they were less knowl-

edgeable than the respondents with tertiary education

were in the recognition that lack of exclusive breastfeed-

ing as a risk factor for pneumonia and the definition of

pneumonia. Importantly, fast/difficult breathing was

recognized equally by both groups as suggestive of

pneumonia. In a country with low illiteracy rate such as

Nigeria this finding may allay fears that campaigns em-

phasizing fast/difficult breathing as trigger for early re-

ferral may be ineffective. Our results suggest that such

campaigns should be driven by healthcare practitioners,

with an additional need to improve the knowledge of the

media practitioners about childhood pneumonia. It is not

uncommon in Nigeria to find articles in the media em-

phasizing the need to keep warm as a way of preventing

pneumonia. And our findings lend some support to this;

respondents with the news media as source of informa-

tion on pneumonia were more likely to report exposure

to cold and not germs as a cause of pneumonia. In con-

trast those who cited health care workers as sources of

pneumonia information identified germs as causes of

pneumonia and lack of EBF as a risk factor. With the

news media as an effective means of public

Authors’ contributions: All the authors except ECI and

BMR conceived the study.

EEN and BMR drafted the proposal.

ECI and EEN collected and analysed the data

All authors reviewed and approved the final manuscript

Conflict of Interest: None.

Funding : None

Acknowledgement

Paediatrics Association of Nigeria gratefully

acknowledges the funding support from the International

Vaccine Access Centre (IVAC) of Johns Hopkins

University Bloomberg School of Public Health for the

2011 World Pneumonia Day celebration and this re-

search. We also appreciate the assistance of Emmanuel

John in data entry.

2

9

Reference

1

.

Black RE, Cousens S, Johnson

HL, Lawn JE, Rudan I, Bassani

DG, et al. Global, regional, and

national causes of child mortality

in 2008: a systematic analysis.

Lancet 2010;375(9730):1969-87.

Kellner JD, Church DL, Mac-

Donald J, Tyrrell GJ, Scheifele D.

Progress in the prevention of

pneumococcal infection. CMAJ

7. Kallander K, Hildenwall H,

Waiswa P, Galiwango E, Peterson

S, Pariyo G. Delayed care seeking

for fatal pneumonia in children

aged under five years in Uganda: a

case-series study. Bull World

Health Organ 2008;86(5):332-8.

8. Kallander K, Nsungwa-Sabiiti J,

Peterson S. Symptom overlap for

malaria and pneumonia--policy

implications for home management

strategies. Acta Trop 2004;90

(2):211-4.

9. Muhe L. Mothers' perceptions of

signs and symptoms of acute respi-

ratory infections in their children

and their assessment of severity in

an urban community of Ethiopia.

Ann Trop Paediatr 1996;16(2):129

-35.

10. Kundi MZ, Anjum M, Mull DS,

Mull JD. Maternal perceptions of

pneumonia and pneumonia signs in

Pakistani children. Soc Sci Med

1993;37(5):649-60.

11. Galvez CA, Modeste N, Lee JW,

Betancourt H, Wilkins RL. Peru-

vian mothers' knowledge and rec-

ognition of pneumonia in children

under 5 years of age. Rev Panam

Salud Publica 2002;11(2):99-108.

12. Uwaezuoke SN, Emodi IJ, Ibe BC.

Maternal perception of pneumonia

in children: a health facility survey

in Enugu, eastern Nigeria. Ann

Trop Paediatr 2002;22(3):281-5.

13. Hudelson PM. The management of

acute respiratory infections in

Honduras: a field test of the Fo-

cused Ethnographic Study (FES).

Med Anthropol 1994;15(4):435-

46.

14. Hudelson P, Huanca T, Charaly D,

Cirpa V. Ethnographic studies of

ARI in Bolivia and their use by the

national ARI programme. Soc Sci

Med 1995;41(12):1677-83.

15. Iyun BF, Tomson G. Acute respira-

tory infections--mothers' percep-

tions of etiology and treatment in

south-western Nigeria. Soc Sci

Med 1996;42(3):437-45.

16. Luby SP, Halder AK. Associations

among handwashing indicators,

wealth, and symptoms of child-

hood respiratory illness in urban

Bangladesh. Trop Med Int Health

2008;13(6):835-44.

2

3

4

.

2

005;173(10):1149-51.

Progress in introduction of pneu-

mococcal conjugate vaccine--

worldwide, 2000-2008. MMWR

Morb Mortal Wkly Rep 2008;57

(42):1148-51.

Johnson HL, Deloria-Knoll M,

Levine OS, Stoszek SK, Freimanis

Hance L, Reithinger R, et al. Sys-

tematic evaluation of serotypes

causing invasive pneumococcal

disease among children under

five: the pneumococcal global

serotype project. PLoS Med

17. Niessen LW, ten Hove A, Hilderink

H, Weber M, Mulholland K, Ez-

zati M. Comparative impact as-

sessment of child pneumonia inter-

ventions. Bull World Health Or-

gan 2009;87(6):472-80.

2

010;7(10).

5

6

.

Sazawal S, Black RE. Effect of

pneumonia case management on

mortality in neonates, infants, and

preschool children: a meta-

analysis of community-based

trials. Lancet Infect Dis 2003;3

(9):547-56.

UNICEF/WHO. The forgotten

killer of children. 2006.